2016 CYC Junior Rowing Summer Program Registration

Transcription

1 2016 CYC Junior Rowing Summer Program Registration Rower s Last Name First Name Age/DOB Address City State Zip Code School Grade Level (Fall 2016) Parent s Last Name First Name Address City State Zip Code Parent s Last Name First Name Address City State Zip Code Emergency Contact Relationship Cell Home. Learn To Row and Advanced Lesson Options 3 Private Lesson Package $240 1 Private Lesson $90 3 Semi Pvt Lesson Pkg $320 ($160/Student) 1 Semi Private Lesson $120 ($60/Student) Lessons are 2 hours. Choose either am or 10 am-12 noon. Slots fill up, so please register early. Week 1 M/Tu/W/Th/F June Week 2 M/Tu/W/Th/F June 27-July1 Week 3 M/Tu/W/Th/F July 4-8 Week 4 M/Tu July Week 5 M/Tu/W/Th/F July Week 6 M/Tu/W/Th/F July Week 7 M/Tu/W/Th/F August 1-5 Week 8 M/Tu/W/Th/F August 8-12 Week 9 M/Tu/W/Th/F August Week 10 M/Tu/W/Th/F August Recreational Summer Rowing 1 Week $60 (Week 4, $30) 5 Weeks $ Weeks $400 Lessons are 2 hours ( am). Week 1 Tu/Th June 21/23 Week 2 Tu/Th June 28/30 Week 3 Tu/Th July 5/7 Week 4 Tu July 12 Week 5 Tu/Th July 19/21 Week 6 Tu/Th July 26/28 Week 7 Tu/Th August 2/4 Week 8 Tu/Th August 9/11 Week 9 Tu/Th August 16/18 Week 10 Tu/Th August 23/25 Varsity Summer Rowing 1 Week $90 5 Weeks $ Weeks $750 Lessons are 2 hours ( am). Week 1 M/W/F/Su June Week 2 M/W/F/Su June 27-July 3 Week 3 M/W/F/Su July 4-10 Week 4 M/W July Week 5 M/W/F/Su July Week 6 M/W/F/Su July Week 7 M/W/F/Su August 1-7 Week 8 M/W/F/Su August 8-14 Week 9 M/W/F/Su August Week 10 M/W/F/Su August Please Indicate By Circling Appropriate Program Choices Including Dates and Number of Weeks Please Circle Method of Payment: Check, Credit Card or CYC Club Charge Checks should be made out to California Yacht Club. A Credit Card form is attached Space cannot be reserved until completed registrations and payment are received. Completed registrations with payment may be handed in to Craig Leeds or Mailed to: California Yacht Club, Attention: Craig Leeds - Junior Rowing 4469 Admiralty Way, Marina del Rey, CA 90292

2 Minor s Health History - Parent s Report Minor s Name: Date of Birth: Sex: Male Female Does your child have the following? Details / Limitations Seizures Heart defect or disease Diabetes Bleeding / clotting disorder Asthma Serious allergies: Insect stings Penicillin Other drugs Food Other Muscle, bone or joint problems Previous injury still affecting Loss of consciousness Physical limitations Surgery in the last year Special fears or conditions No Yes Note: If you answered Yes to any of the above, you must provide a doctor s release before your child will be allowed to participate in the Junior Rowing Program. CYC reserves the right in its sole discretion to decline any participant for safety reasons. Is there any thing else we should know about your child? I certify that the above information is true, correct and complete. Signature of Parent or Guardian Date Print Name

3 PARENTAL CONSENT FOR MEDICAL AND/OR DENTAL CARE OF A MINOR Minor s Name: I, the undersigned, am a parent having legal custody or other person having legal custody or guardianship of the above-listed Minor. In consideration of said Minor s participation in the Junior Rowing Program of California Yacht Club (CYC), related activities and use of CYC s facilities, I hereby authorize CYC staff to consent to medical or dental care, or both, of said Minor, including any X-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment or hospital care under the general or special supervision and upon the advice of or to be rendered by a licensed physician or dentist, all at my sole expense. Any revocation of this consent must be evidenced in writing and will result in the Minor s immediate dismissal from the Program. Non-Liability of CYC I agree that in no event will CYC, its parent companies, affiliates, or the partners, owners, directors, officers, employees, agents and committee persons of any of them have any liability whatsoever arising from or in connection with any medical or dental care rendered or to be rendered pursuant to the above Consent. I certify that I have carefully read, understand and agree to the above. Address City, State, Zip Tel. (day) Tel. (eve) Tel. (cell) Medical Insurance Carrier Plan/Group Number Alternate Emergency Contact Name Tel. (day) Tel. (eve) Tel. (cell)

4 Assumption of Risk, Liability Waiver, Release and Indemnification Agreement Please Read Carefully Minor s Name: I, the undersigned, am a parent having legal custody/person having legal custody or legal guardian of the above-listed Minor. I wish to voluntary enroll the Minor in the California Yacht Club (CYC) Junior Rowing Program (the Program). In consideration of the Minor s participation in this voluntary recreational activity and use of CYC facilities, I acknowledge and agree as follows, for myself, the Minor and the Minor s heir, representatives and assigns: 1. I understand that risks exist in the Program and shoreside activities, including but not limited to, the risks of serious physical injury, death or permanent disability from car accident, falling, boat collision, capsizing and drowning. I freely assume all risks, including unforeseen risks. CYC is not my insurer. I will maintain insurance as prudent for the protection of the Minor and myself, including medical and liability coverages. 2. To the fullest extent permitted by law, I promise not to sue, I forever release and agree to indemnify and hold harmless CYC from and against any and all claims, damages, liabilities, losses, suits, costs and expenses including attorney fees, for personal injury to the Minor or any other person, and loss of any property, arising from the Minor s participation in the Program and shoreside activities on or off CYC premises, and including any active or passive negligence of CYC, such as negligent rescue. My obligations under this paragraph shall survive the termination of the Minor s participation in the Program. 3. I represent that the Minor is in good health, is able to safely undertake rowing activities, and can swim well enough in the event his/her boat capsizes to avoid any resulting danger; and that the Minor is capable of comprehending instruction, following directions and observing proper safety precautions. I agree to abide by the decisions of the Program s Head Instructor if he/she finds it necessary to discipline or dismiss the Minor for lack of attention, misbehavior or failure to follow safety precautions. 4. For the purpose of the Agreement, CYC includes its parent companies, affiliates, and the owners, partners, directors, officers, employees, agents, and committee persons of any of them. This Agreement contains all of the understandings between me and CYC regarding the subject matter hereof, and may be modified only in a writing signed by the parties. I am not relying upon any promise, representation or inducement not contained herein. The above waiver, release and indemnity provisions are continuing obligations and intended to be as broad, comprehensive and inclusive as permitted by law, but are not intended to assert any claim or defense prohibited by law. The provisions of this Agreement shall be interpreted in such a way so as to render them valid whenever possible, and any ambiguity shall not be strictly construed against CYC. If any part of this Agreement is held invalid by a court or arbitrator having jurisdiction, the remainder shall continue in full force and effect. I certify that I have carefully read, understand and agree to the above.

5 4469 Admiralty Way Marina Del Rey, CA (310) CYC JUNIOR ROWING I hereby authorize The California Yacht Club to charge my: Master Card Visa American Express In the amount of: This is a one time charge: This is a recurring charge: Description of Charges: Credit Card Information: Credit Card Number: Exp Date: Name As It Appears On Card: Billing Zip Code: Security Code: Authorized Signature: Date: Card User Information: Name: Street Address: City: State: Zip Code: Phone: This charge will be described by your credit card company as LA Athletic Club-M